Inspection on 05/12/05 for Christ The King

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Christ The King 08/05/08

Christ The King 02/11/07

Christ The King 15/11/06

Christ The King 10/08/05

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Tankerville Road 68 Tankerville Road Streatham London SW16 5LP Lead Inspector Lynne Field Unannounced Inspection 5th December 2005 & 9th February 2006 10:00 Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tankerville Road Address 68 Tankerville Road Streatham London SW16 5LP 020 8480 5028 020 8480 5031 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Healthcare Professionals Services Ltd Ms Bibi Haniff Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/08/05 Brief Description of the Service: Christ the King, (Tankerville Road) is a small residential care home that aims to provide 24-hour care and support in an independent living setting in the community. It can take up to six service users, men or women aged 18 –65, who are experiencing mental health difficulties and need continual rehabilitation in the community following their discharge from hospitals or from other care institutions. There are six single bedrooms, four with en suite facilities. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection visit to the home since it was registered on 19th October 2004. A return visit was made on 9 February 2006 to check additional records. Both days of the inspection were well facilitated by the nurse in charge of the shift, who gave the inspector a tour of the home. The registered provider contacted the inspector by phone during the course of the inspection. Four service users were spoken to during the course of the inspection, one who has recently moved in said they liked the home and were settling in well. There was a level of commitment continues to be displayed by the registered provider, registered manager and staff team to ensure they were meeting the needs of the service users and complying with the standards. The manager has successfully made an application to become the registered manager since the first inspection in August 2005. What the service does well: What has improved since the last inspection? What they could do better: The home could make sure all service users do not have to miss going on outings because one of the service users have changed their mind and decided not to go out by having a contingency plan in place. The dispensing and record keeping of medication must be correct at all times. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Families and other professionals are involved when reviews are held. Care plans are thorough and reflect service user needs and goals, which are reviewed monthly, or when the need arises. EVIDENCE: Two service users have come to live at the home since the last inspection in August 2005, so there are now four service users living at the home. Both new service user files were inspected and contained the relevant assessment and summary of needs. The nurse in charge explained that a trained nurse always went to see the service user to do an assessment where the service user was living. The service user would then come to spend time in the home and meet all the service users living there. If they liked it they would come for a day with any friends or family. If this was successful there would be a discharge meeting when the whole care package is put together. The inspector noted the care plans gave a thorough description of service user behaviours, reactions and preferences and how the service user was to be treated. There were immediate, medium term and long-term goals and these are reviewed monthly and recorded. Risks were identified and how these would be minimised, with actions agreed and recorded. Individual risk assessments had been carried out and staff the inspector spoke to, were familiar with the risk assessments and updates. For Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 9 instance one service user is very independent and it has been agreed he can stay out for up to 24hours without any action being taken. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Families and other professionals are involved when reviews are held. Care plans are thorough and reflect service user needs and goals, which are reviewed monthly, or when the need arises. EVIDENCE: Both new service user files were seen and the inspector noted the care plans gave a thorough description of service user behaviours, reactions and preferences and how the service user was to be treated. The registered manager told the inspector care plans from the last placement would be followed and developed if appropriate to ensure continuity of care. This would be done at the discharge meeting involving the service user and all the professionals involved. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 11 The registered manager said the risk assessments from the previous placement would be checked and then the home would develop their own risk assessments to suit the service users changing needs. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 Service users engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Service users’ rights and responsibilities are respected. EVIDENCE: The activities programme is designed to meet each service user’s individual needs. Service users are also encouraged to take part in activities commissioned by outside specialists such as reflexology, aromatherapy, healthy eating etc. In this way service user’s are supported and encouraged to take part in activities that are enjoyable, beneficial to their mental and physical health and which give them the opportunity to develop skills within their abilities. A member of staff said at times service users were reluctant to go out and staff needed persuasive skills to encourage them to go the arranged activities. The inspector observed a member of staff encouraging a service user to take their daily shower and to get dressed. This was done in a calm, respectful Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 13 manner and when the service user did not respond the member of staff left it for a short while before again suggesting to the service user they take a shower using by using a different approach and words. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Staff provide sensitive and flexible personal support and service user’s physical and emotional health needs are met most of the time. Medication administration was found to be improperly documented and service users are not always getting the medication prescribed. EVIDENCE: During the inspection, the inspector saw that a member of staff had to prompt a service user to have a shower and noted it was carried out sensitively and in a way that ensures service user’s privacy and dignity. Same gender personal care is given whenever possible. One service user comes and goes as he pleases and regularly goes out on their own to draw money from the bank or buy personal items. Each service user has household chores that they do on a regular basis. These are discussed and agreed at the service users meeting, with service users stating what they want to do. One service user told the inspector they would like to go out more, but there was not always enough staff. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 15 The inspector was concerned to learn some outings had to be cancelled due to lack of staff. See Standard 33. Only the trained nurses dispense medication. The local pharmacist comes in to do refresher training for all staff. Service users medication was checked and there were discrepancies found. The home does not operate a running total system and so it was not possible to know when this had happened. The way one medication was written on the medication chart was confusing as different strengths of medication were included on one line. Medication charts must be clearly written and a running total of medication left must be kept. Different strengths of the same medication must be recorded on separate lines. Tipex must not be used on any legal document. Errors in writing must be crossed out by putting on line through so error can still be seen and initialled by the person making the correction. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Practices and training at the home ensure that service users are protected from abuse. Service users confirmed that they felt their views were listened to and acted upon. EVIDENCE: The home has adult protection policies and procedures in place including whistle blowing and an appropriate restraint policy, stating that restraint should be used only as a last resort. The inspector noted that no complaints had been made since the last inspection. Service users meetings are held every two months. The inspector was shown minutes of the meetings and noted that service users are encouraged to speak out about any concerns they may have. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 The home is safe and comfortable with adequate private and shared space, toilets and bathrooms. Service users’ bedrooms promote their independence. The home is well maintained and furnished. EVIDENCE: The inspector was shown around the premises and the bedrooms of those service users who gave permission. The home is generally well maintained, and decorated and furnished in a comfortable style. The home has 6 single bedrooms over three floors. All bedrooms are of adequate size with four having en-suite facilities. Four service users spoken to confirmed that they were happy with their rooms and that they had all of the furniture and fittings they require. One of the new service users told the inspector they were happy with the home and enjoyed the meals. There is a range of communal spaces, including smoking and no smoking areas and a pleasant garden with a raised patio area. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 Service users confirmed that they felt that competent staff supported them and records indicate the staff team is well qualified but the registered provider must get confirmation that the care manager is confident the staff team can meet the needs of the service users placed in the home at all times. The staffing levels at the home adequate for the most part are good but need to be reviewed to ensure service users personal development and social needs can be met. EVIDENCE: The registered provider and the senor nurse on duty on the day of the inspection told the inspector the home was advertising to fill the homes job vacancies and hoped to recruit staff early in 2006. The inspector was shown the staff rota and noted that there was always a Registered Mental Nurse on shift as agreed with the relevant care manager who indicated they would not be happy to place a service user in the home unless there was an RGM on every shift, particularly at night when problems when some service users can become more unsettled. The registered manager said that the care managers were satisfied that the staff on each shift have the level of expertise to meet the needs of the service users placed in the home. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 19 The inspector noted that some planned outings had been cancelled. When the staff were asked about this they explained that if one service user decided at the last minute they did not want to go, the outing had to be cancelled because there were not enough staff to be able to take the other service users out safely and at other times service users were not able to go when they wanted to because there were not enough staff on duty to go to the different activities each service user wanted to go to. The registered provider must look at the over all staffing levels and ensure there are enough staff on duty to meet the social needs of the service users. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Service users felt that their views were listened to at service users meetings. the results of the consultation exercise had not been summarised and been made available to them, and the annual development plan had not been reviewed, to evidence that review and development of the service is based on the views of service users. The health, safety and welfare of service users is promoted and protected though a risk assessment requires adjustment to fully evidence this. EVIDENCE: Service users are given the opportunity to give their views of the home at service users meetings which were recorded in the minutes of the meeting that are held every two months. There had been no formal service user survey where the views of the service users and their relatives and professionals were sought. This needs to be set up and forms in the survey tailored to the needs of the different stakeholders. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 21 The registered provider needs to start to conduct monthly, unannounced visits to review the service, copies of the reports these should be sent to CSCI to evidence the provider’s monitoring of the service. Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 X X x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tankerville Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000055922.V264509.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement The registered person must ensure that all medication signed for as given to a service user, has been given. The registered person must review and assess the staffing levels in relation to the needs of the service users, making amendments to the staffing levels to ensure service users personal development and social needs can be met. The registered person must ensure that copies of reports of visits conducted in accordance with Regulation 26 of the Care Homes Regulations are sent to CSCI Southwark Office. The registered person must ensure service users are formally consulted as evidence that the views of service users are taken into account in reviewing and developing the service. Timescale for action 20/03/06 2 YA33 18(1)(a) 20/03/06 3 YA39 26 20/03/06 4 YA39 24 20/03/06 Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tankerville Road DS0000055922.V264509.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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